3 Taking Medication Histories
Chapter 4 Physical Assessment Skills
A, Single tube. B, Double tube
(From Sanders MJ: Mosby’s paramedic textbook, ed 3, St Louis, 2006, Mosby.) Sphygmomanometer
The sphygmomanometer includes a cuff (a cloth-covered inflatable rubber bladder), a valved rubber bulb for inflating the cuff, and a manometer that measures the cuff pressure. Blood pressure cuffs (Figure 4-6) come in a variety of sizes to accommodate a variety of arm sizes (Table 4-3).1 Use an appropriately sized cuff; cuffs that are too short or too narrow falsely
elevate the blood pressure, whereas cuffs that are too big falsely decrease the blood pressure. The cuff width should be about 40% of the limb circumference, and the cuff length should be about 80% of the limb circumference. There are two types of manometers: the classic wall-mounted mercury-filled glass tube and the aneroid dial (Figure 4-7). Mercury-based manometers are durable, are easy to read, and provide consistent, accurate measurements but are bulky and must be in an upright position and at eye level for accurate measurements. Mercury is a hazardous substance; many health care professionals prefer to use aneroid manometers, which do not contain mercury. Aneroid manometers are relatively inexpensive and work in all positions but are delicate and must be recalibrated if bumped or dropped. There are also a variety of automatic digital manometers.
Full-size image (34K) Figure 4-6.
Blood Pressure Cuffs.
A (from top), Large adult, adult, and child cuffs. B (from top), Infant and neonatal cuffs.
(From Seidel HM: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.) Table 4-3. Blood Pressure Cuff Sizing
Cuff Arm Circumference Range at Midpoint (cm) Newborn ≤6
Infant 6-15 Child 16-21 Small adult 22-26 Adult 27-34 Large adult 35-44 Adult thigh 45-52
Full-size image (31K) Figure 4-7.
Sphygmomanometers.
Mercury-based (left) and aneroid (right) sphygmomanometers.
(From Gerdin J: Health career today, ed 4, St Louis, 2007, Mosby.) Ophthalmoscope
The ophthalmoscope consists of a head and a handle (Figure 4-8 and Figure 4-9). The head contains viewing lenses and beam selection controls. The viewing lens control (lens wheel) is used to focus the instrument. Positive diopter values (black or green numbers depending on the manufacturer) are used to correct the focal length for nearsighted eyes; negative diopter values (red numbers) are used to correct the focal length for farsighted eyes. The beam control wheel is used to select the aperture (beam); aperture selection depends on the structure being assessed (Table 4-4). The light intensity is adjustable on some ophthalmoscopes.
Full-size image (21K) Figure 4-8.
The Ophthalmoscope.
(From Sanders MJ: Mosby’s paramedic textbook, ed 3, St Louis, 2006, Mosby.)
Full-size image (27K) Figure 4-9.
Components of the Ophthalmoscope.
Table 4-4. Ophthalmoscope Apertures
Aperture Use
Large white (wide angle)
Assess dilated pupils
Intermediate white Assess undilated pupils and details of small areas Small white Assess undilated pupils and details of small areas Red-free (bluish
green filter)
Assess retinal vessels and hemorrhages (red appears black on a greenish background instead of the usual red on orangish background with white light)
Macular Assess macula
Slit Assess cornea, anterior chamber, and elevations or depressions in the fundus
Fixation Locate lesions and measure eccentric fixation Otoscope
The otoscope consists of a head and a handle (Figure 4-10 and Figure 4-11). The otoscope is used to assess the ear canal and tympanic membrane. The head consists of a speculum and magnifying glass and can be rotated up and down into several positions. Disposable speculum covers are available in a variety of sizes to fit most ear canals. Most otoscopes and
ophthalmoscopes are available as interchangeable heads that fit the same handle.
Full-size image (31K) Figure 4-10.
The Otoscope.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.)
Full-size image (19K) Figure 4-11.
Components of the Otoscope.
Reflex Hammer
The reflex hammer, also known as a percussion hammer, consists of a rubberlike head attached to a handle (Figure 4-12). The reflex hammer primarily is used to elicit superficial and deep tendon reflexes but may be used to create percussion notes (e.g., in chest percussion). The Taylor, or tomahawk-style, reflex hammer has a triangular head. Several other styles are
available. Generally the pointed end of the head of the reflex hammer is used to strike the tendon and elicit the reflex.
Full-size image (26K) Figure 4-12.
Reflex Hammers.
A, Tomahawk-style hammer. B, Neurologic hammer.
(From Seidel HM: Mosby’s guide to physical examination, ed 6, St Louis, 2006, Mosby.) Tuning Fork
Tuning forks, typically aluminum, consist of a stem (handle) and two prongs that form a U- shaped fork (Figure 4-13). The tuning fork vibrates at a set frequency after being struck on the heel of the hand and is used to assess vibratory sensation and hearing (air conduction and bone conduction). Hold the tuning fork by the stem, not the prongs. Tuning forks are available in a wide range of frequencies (64 Hz to 4096 Hz); 128 Hz is a commonly used frequency for screening.
Full-size image (12K) Figure 4-13.
Tuning Forks.
Tuning forks for vibratory sensation (Top) and auditory testing (Bottom).
(From Seidel HM: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.) Other Equipment
Other useful equipment includes a light source (penlight or flashlight) and tongue depressors.
The light source is used to assess pupillary response to light and to facilitate closer observation of other visible features (e.g., skin lesions, carotid artery pulsations). Tongue depressors, used to facilitate inspection of the oropharynx, are made of wood and are available in individual (sterile)
peel-down pouches or in nonsterile bulk packaging. The standard adult tongue depressor is 6 × 11⁄16 inches. Other sizes are available (junior, 51⁄2 × 5⁄8 inches; infant, 41⁄2 × 3⁄8 inches). A sterile tongue depressor broken in half is sometimes used to test the neurologic response to a sharp stimulus.
Vital Signs
The vital signs include the heart rate, respiratory rate, blood pressure, and temperature. Along with height and weight, the vital signs provide important screening and diagnostic information as well as monitoring data for assessment of short-term and long-term response to medication therapy.
Techniques
Arterial Pulse
To assess the arterial pulse, determine the heart rate, the strength of the pulse, and the regularity of the pulse (Box 4-2). The radial artery is commonly used to assess pulse, although any
accessible large artery (e.g., femoral, carotid) may be used (Figure 4-14). The radial artery is located in the wrist below the thumb and between the flexor carpi radialis and abductor pollicis longus tendons. Gently compress the artery with the fingertips; do not palpate with the thumb (the pulse in the examiner’s thumb may confuse the assessment of the patient’s pulse).
Determine the number of heartbeats per minute (beats/min, BPM) by counting the number of pulses in 15 seconds and multiplying by 4 (or use any combination that gives the per-minute rate). The strength of the pulse is described as “normal,” “weak,” or “bounding” (stronger than normal). Determine if the pulse is regular (evenly spaced beats) or irregular (unequally spaced beats). If irregular, determine if the sequence has a repeating pattern (regularly irregular) or not (irregularly irregular).
Box 4-2.
Arterial Pulse Checklist
•
□ Locate the radial pulse.
•
□ Palpate with the fingers (not thumb).
•
□ Report/record the per-minute rate. (Example: The heart rate is 80 beats per minute.)
•
□ Report/record the strength. (Example: The pulse is normal strength.)
•
□ Report/record the regularity. (Example: The pulse is regular.)
Full-size image (22K) Figure 4-14.
Arterial Pulse.
(From Seidel HM: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.) The normal heart rate is approximately 60 to 100 beats/min with normal strength and regular beats. Bradycardia, a slow heart rate (<60 beats/min), is caused by medications such as beta- adrenergic blocking drugs and digoxin and by sinus node or atrioventricular (AV) node dysfunction. Tachycardia, a fast heart rate (>100 beats/min), is caused by anxiety, volume depletion, fever, exercise, and inotropic drugs such as epinephrine and dobutamine. A weak pulse is caused by conditions associated with decreased cardiac output (e.g., heart disease, hypovolemia). A strong (bounding) pulse is caused by conditions associated with increased cardiac output (e.g., anxiety, pain, hyperthyroidism). The heart rate is normally regular, with evenly spaced beats. An irregular heart rate, characterized by irregularly spaced beats, may be completely irregular (no identifiable pattern) or regularly irregular (repetitive abnormal pattern).
Cardiac dysrhythmias are commonly associated with irregular heartbeats.
Respiration
Unobtrusively observe the patient breathe (a patient aware of being watched will control his or her breathing) (Figure 4-15). Determine the per-minute respiratory rate, the pattern of breathing, and whether the patient is using accessory muscles to breathe (Box 4-3). One technique for observing the patient’s respiration unobtrusively is to position the patient so that the patient’s chest can be observed while the pulse is assessed. Continue to hold the patient’s wrist and watch the clock after completing the assessment of the pulse but count the respiratory rate. Note that one breath equals one respiratory cycle (inspiration plus expiration). Determine the number of breaths per minute (breaths/min, BPM) by counting the number of breaths in 15 seconds and multiplying by 4 (or use any combination that gives the per-minute rate). Observe whether the pattern of breathing is normal (normal depth of breathing and regular rate) or abnormal (shallow, deep, shallow then deep, periodic apnea, etc.) and note whether the patient is using the
sternocleidomastoid and/or abdominal muscles (transverse, oblique) to assist the breathing.
Full-size image (32K) Figure 4-15.
Counting Respirations.
When counting respirations, leave the hands in place as if still assessing the patient’s pulse.
(From Young A: Kinn’s the medical assistant: an applied-learning approach, ed 10, St Louis, 2007, Saunders.)
Box 4-3.
Respiration Checklist
•
□ Unobtrusively observe the patient’s breathing.
•
□ Report/record the rate. (Example: The respiratory rate is 12 breaths per minute.)
•
□ Report/record the pattern. (Example: The respiratory pattern is normal.)
•
□ Report/record the use of accessory muscles. (Example: No accessory muscles used.) The normal respiratory rate is 12 to 20 breaths/min. Tachypnea, a fast respiratory rate (>20 breaths/min), is caused by pain, anxiety, exercise, and respiratory failure. Bradypnea, a slow respiratory rate (<12 breaths/min), is caused by medications such as narcotics and medical conditions associated with elevated carbon dioxide levels. The respiratory rate is normally regular, with evenly spaced inspirations and expirations, and of normal tidal volume (volume per breath). Abnormal breathing patterns include abnormally fast and deep breathing (Kussmaul’s respiration; associated with metabolic acidosis), fast and shallow breathing (associated with obstructive airway disease), slow and shallow breathing (associated with narcotics), apnea (no breathing; associated with sleep apnea), and Cheyne-Stokes breathing (periods of apnea
alternating with cycles of increasing and decreasing depth of breathing; associated with diseases that affect the central respiratory control center) (Figure 4-16).
Full-size image (77K) Figure 4-16.
Respiratory Patterns.
Vertical lines indicate depth of respiration. Horizontal lines indicate the relative respiratory rate.
(From Seidel HM: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)
Blood Pressure
Patients should be at rest for at least 15 minutes before the blood pressure is measured, and if the patient is sitting, the patient’s feet should be flat on the floor (the blood pressure will be falsely high if the legs dangle) (Box 4-4). Select an appropriately sized cuff and palpate for the brachial artery before positioning the cuff on the arm. Place the arterial portion of the cuff directly over the brachial artery with the bottom of the edge approximately 2.5 cm above the antecubital crease (Figure 4-17). Support the patient’s arm at the level of the heart; tensed muscles falsely elevate the blood pressure (the blood pressure will be falsely high if the arm is below the level of the heart and falsely low if the arm is above the level of the heart) (Figure 4-18).
Box 4-4.
Blood Pressure Checklist
•
□ Make sure the patient has both feet flat and supported on the ground.
•
□ Ask the patient if the patient knows his or her blood pressure.
•
□ Palpate for the brachial pulse before putting the cuff on the patient’s arm.
•
□ Align the cuff with the brachial artery.
•
□ Position the bottom of the cuff 2.5 cm above the antecubital crease.
•
□ Place the diaphragm of the stethoscope over the brachial artery.
•
□ Support the patient’s arm at the level of the heart.
•
□ Close the valve on the bulb and pump the cuff to 20 mm Hg over the expected systolic blood pressure.
•
□ Open the valve and slowly release the pressure at a rate of 2-4 mm Hg/sec.
•
□ Deflate and remove the cuff.
•
□ Report/record the systolic and diastolic pressures. (Example: The blood pressure is 120 over 80 mm Hg.)
Full-size image (30K) Figure 4-17.
Blood Pressure Cuff Position.
Full-size image (39K) Figure 4-18.
Blood Pressure Technique.
Support the arm at the level of the heart.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.) Place the stethoscope over the brachial artery and inflate the cuff to about 20 to 30 mm Hg over the predicted systolic blood pressure (SBP). Deflate the cuff slowly (approximately 2 mm Hg/sec) (SBP will be falsely low and the diastolic blood pressure [DBP] falsely high if the deflation rate is too fast; the DBP will be falsely high if the deflation rate is too slow). Do not reinflate the cuff after partial deflation; cuff reinflation causes venous congestion and inaccurate blood pressure measurements. There are no audible sounds (Korotkoff sounds) until the cuff pressure approximates the SBP; the SBP is the pressure at which at least two Korotkoff sounds are audible.
Korotkoff sounds (tapping sounds) are created by turbulent flow through the partially occluded artery. Each heartbeat creates a sound as the bolus of blood encounters the partially occluded artery; the tapping sound varies with the degree of arterial occlusion (Table 4-5). As the pressure falls, the sounds become louder and then slowly diminish before disappearing altogether. The DBP is the pressure at which the beats are not longer audible. The tapping sounds may disappear during phase II or III (see Table 4-5) and then reappear as the arterial pressure falls. This is called an auscultatory gap and is sometimes observed in elderly patients and hypertensive patients. Depending on the clinical situation, it may be necessary to obtain the blood pressure in both arms or in more than one body position (i.e., sitting and standing, sitting and supine).
Table 4-5. Korotkoff Sounds Phase Description
Phase I First clear, low-pitched tapping sounds (onset corresponds with systolic blood pressure)
Phase II Softer and longer tapping sounds Phase
III
Reappearance of crisp and clear tapping sounds Phase
IV
Muffled softer tapping sounds
Phase V Sounds disappear (last audible tapping sound corresponds with the diastolic blood pressure)
Normal blood pressure is defined as an SBP of less than 120 mm Hg and a DBP of less than 80 mm Hg (Table 4-6).2 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) defines hypertension for adults 18 years of age and older as beginning at 140/90 mm Hg based on the average of two or more proper measurements at each of two or more office or clinic visits.2 Patients may have isolated systolic hypertension (SBP ≥140 mm Hg with DBP <90 mm Hg) or isolated diastolic hypertension (SBP <140 mm Hg with DBP ≥90 mm Hg).
Table 4-6. Blood Pressure Classification
From Chobanian AV, Bakis GL, Black HR, et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Hypertension 42:1206-1252, 2003.
Classification∗ Systolic Blood Pressure (mm Hg) Diastolic Blood Pressure (mm Hg)
Normal <120 <80
Prehypertension 120-139 80-89
Stage 1 hypertension 140-159 90-99
Stage 2 hypertension ≥160 ≥100
∗ Classification is determined by the higher of the systolic blood pressure and diastolic blood pressure.
Temperature
Body temperature is used to screen for illness and to monitor patient response to drug therapy.
The measured temperature varies depending on where the body temperature is measured (oral cavity, rectum tympanic membrane, axilla, ear, temporal artery, central line, bladder) and the device used to measure the temperature (oral thermometer, temperature-sensitive crystal, thermal scanner, thermistor on pulmonary artery catheter, etc.) (Figure 4-19). Other variables include the time of day and probably the patient’s gender (gender differences have been described, but specific guidelines are not currently available). Oral temperature measurements are influenced by drinking hot and cold beverages and chewing gum. The core body temperature as measured by inserting a pulmonary artery catheter with a thermistor into the pulmonary artery is considered the gold standard body temperature, but this technique is too invasive for routine assessments.
Digital thermal scanning thermometers are quick and easy to use but rely on proprietary predictive algorithms and are therefore less accurate than other technologies. Record the temperature, date and time of day, and route and instrument used to obtain the temperature.
Full-size image (85K) Figure 4-19.
Thermometers.
1. Glass thermometers: a, oral axillary (long slender tip), b, rectal (stubby tip), c, oral axillary (pear-shaped tip). 2. Digital thermometer. 3. Disposable thermometer. 4. Electronic
thermomenter. 5. Tympanic thermometer. 6. Temperature-senstive tape. 7. Temporal artery thermometer.
(From Sorrentino S, Gorek B: Mosby’s textbook for long-term care nursing assistants, ed 5. St Louis, 2007, Mosby.)
Normal oral body temperature is 37° C (98.6° F).3 Fever is generally accepted to be an oral body temperature of 38° C (100.4° F) or higher. Oral body temperature is 1° lower than rectal body temperature and axillary temperature is 2° lower than rectal body temperature.
Height and Body Weight
The patient’s height and body weight are not considered vital signs but are useful screening and monitoring parameters and are components of the body mass index (BMI)
equation:BMI(metric)=weight in kilograms÷2(height in meters)
The waist circumference and waist/hip ratio (WHR) are additional screening and monitoring parameters (WHR = waist circumference ÷ hip circumference). The waist circumference is measured at the narrowest part of the waist. The hip circumference is measured at the widest part of the hips. For both measurements, keep the tape measure parallel to the ground.
The BMI (Table 4-7) assesses body fat and, when considered with waist circumference, WHR, and other risk factors (hypertension, increased low-density lipoprotein cholesterol [LDL-C], decreased high-density lipoprotein cholesterol [HDL-C], increased triglycerides, elevated blood glucose level, family history of cardiac disease, physical inactivity, and cigarette smoking) is predictive of coronary heart disease and cardiovascular mortality.5 But BMI underestimates body fat in people with less muscle mass than normal (e.g., the elderly), overestimates body fat in people with more muscle mass than normal (e.g., athletes), and does not provide information regarding fat distribution, an important determinant of risk for several diseases, including coronary heart disease, metabolic syndrome, and obstructive sleep apnea. Abdominal fat is assessed by measuring the waist circumference and the WHR (Figure 4-20). A waist
circumference of more than 40 inches in men and more than 35 inches in women is associated with increased risk for cardiovascular and metabolic disease. A WHR of less than 0.85 for men and less than 0.75 for women is considered excellent and is associated with low risk; WHRs of 1 or higher are associated with increased risk.
Table 4-7. Body Mass Index (BMI) Classification4
From: Screening for Obesity in Adults. What’s New from the USPSTF? AHRQ Publication No.
04-IP002, Rockville, Md, December 2003, Agency for Healthcare Research and Quality.
Available a 2009.
Classification BMI Underweight <18.5 Normal weight 18.5-24.9 Overweight 25-29.9 Class I obesity 30-34.9 Class II obesity 35-39.9 Class III obesity ≥40